the Medical Statistics training slides

Interpreting Basic Statistics
Beginners’ statistics for assessing the effectiveness of an
intervention
Tom Osborne, Librarian
Basic Medical Statistics
 Statistics
which compare risks
 Statistics which test confidence
 Forest Plots
 Statistics which analyse clinical
investigations and screening
 Statistics which test differences
Statistics Which Compare Risk
CER & EER
Control event rate (CER) = Risk of outcome event in
control group
=
no in the control group with event
total no in the control group
=?
Risk of mortality in the control group is ?%
Experimental event rate (EER) = Risk of outcome
event in experimental group
=
no in the experimental group with event = ?
total no in the experimental group
Risk of mortality in the statin group is ?%
Relative Risk (RR)
•
•
•
•
•
Compares the risk of having an event between
two groups
RR=1 the event is equally likely in both groups
RR<1 event is less likely to happen than not (i.e. the
intervention reduces the chance of having the event)
RR>1 event is more likely to happen than not
(increases the chances of having the event)
The smallest value an RR can take is 0
Relative Risk
Compares the risk of having an event between two
groups
RR = EER /CER =
Relative Risk/Odds Ratio
Relative Risk Reduction (RRR)
•
The reduction in rate of the event in the treatment group relative
to the control group
•
RRR = 1 – RR = ?
•
The relative risk was ?% lower for statin than the control group or
there is a ?% reduction in risk for patients in the statin group
relative to those patients in the control group.
Absolute Risk Reduction (ARR)

The difference in absolute risk of a particular event
between 2 groups. Also know as the risk difference.

ARR = 0 no difference between the 2 groups

ARR = CER – EER = ?
 The absolute risk of mortality was ?% lower in the statin group
than in the control group or statins reduces the risk of mortality by
?%
Numbers Needed to Treat (NTT)
 The number of people who need to be treated in order to prevent
one additional outcome of interest.
 NNT = 1/ARR = ?
 ? patients have to be treated with statin in order to avoid one
additional death
RR vs. ARR

Consider 2 RCTs of a new drug done on 2
populations at risk of a heart attack over 10 years

RCT1 (n=200)
– High risk group: 90/100 of those
not receiving the drug
(control) will have a heart attack. 60/100 of those receiving
the drug will have a heart attack.

RCT 2 (n=200)
– Low risk group: 3/100 of those
not receiving the drug
(control) will have a heart attack. 2/100 of those receiving the
drug will have a heart attack.


RR =
RRR =
 The relative risk was ?% lower for new drug than the control
group for high risk patients
RR
=
RRR =
The relative risk was ?% lower for new drug than the control
group for low risk patients



ARR =
NNT =
? patients have to be treated with statin to avoid one additional death
ARR
=
NNT =
? patients have to be treated with statin to avoid one additional
death
Odds Ratio





Expresses the odds of having an event compared with not
having an event:
OR=1 the event is equally likely in both groups (i.e. no difference)
OR<1 event is less likely to happen than not (i.e. the treatment reduces
the chance of having the event)
OR>1 event is more likely to happen than not (increases the chances of
having the event)
The smallest value an OR can take is 0
Calculate the Odds Ratio:

OR = (498/4014) ÷ (633/3869) ≈ ?

The odds ratio for mortality for people taking statins compared to the
control is ?
Online Calculator: http://www.hutchon.net/confidor.htm
Statistics Which Test Confidence
P-values



The probability (ranging from zero to one) that the results
observed in a study could have occurred by chance. (Bandolier)
Convention states we accept p-values of p<0.05 to be statistically
significant. (Bandolier)
The P value is computed from the F ratio which is computed from
the ANOVA table.
P value
Interpretation
P<0.05
The result is unlikely to be due to chance, a statistically
significant result.
P>0.05
The result is likely to be due to chance, not a statistically
significant result.
P= 0.05
the result is quite likely to be due to chance, not a statistically
significant result.
Significant at Cut Off?
P value
P<0.001
P=0.049
P>0.051
P<0.05
P<0.01
Confidence Intervals
 What is a confidence interval?
– If the same trial were to be repeated many
times over, the 95% CI would define the range
of values within which the true population
estimate would be found in 95% of occasions
 What can a confidence interval indicate?
– Whether a result is statistically significant
– Indication of precision
– Strength of the evidence
Online [email protected]
http://www.hutchon.net/confidor.htm
Interpreting CIs
Measure of
Interpretation of CI
effect
Binary outcome, If a CI for an RR or OR, includes 1 then we are
unable to demonstrate statistically significant
Ratio
difference between the two groups
Continuous
outcome, Mean
difference
If a CI for a RRR, ARR, includes 0 we are unable to
demonstrate a statistically significant difference
between the two groups compared
Confidence Intervals
“Trials examined the effect of education
programmes on improvement in lung function in
asthma sufferers”
Study
Mean difference (95% CI)
Christiansen
Weingarten
Toelle
0.35 (-0.28-0.99)
1.24 (0.26-2.22)
0.47 (0.18-0.75)
Are educational programmes effective at increasing lung function?
Which study/studies show a significant result?
Which study demonstrated the strongest evidence?
Measure of effect
Interpretation of CI
Binary outcome,
Ratio
If a CI for an RR or OR, includes 1 then we are unable to demonstrate statistically
significant difference between the two groups
Continuous outcome,
Mean difference
If a CI for a RRR, ARR, includes 0 we are unable to demonstrate a statistically
significant difference between the two groups compared
Forest Plots
Forest Plots
“Effect of probiotics on the risk of antibiotic associated diarrhoea”
The label tells you what the comparison and
outcome of interest are
Effect of probiotics on the risk of antibiotic associated diarrhoea
Scale measuring treatment effect.
Take care when reading labels!
Effect of probiotics on the risk of antibiotic associated diarrhoea
Treatment effect sizes for each study
(plus 95% CI)
Effect of probiotics on the risk of antibiotic associated diarrhoea
The % weight given to each study in the
pooled analysis
Effect of probiotics on the risk of antibiotic associated diarrhoea
Point estimate
Horizontal lines are confidence intervals
Diamond shape is pooled effect
Horizontal width of diamond is confidence interval
Effect of probiotics on the risk of antibiotic associated diarrhoea
The vertical line in middle is the line of no effect
For ratios this is 1, for means this is 0
Effect of probiotics on the risk of antibiotic associated diarrhoea
Exercise
25
Statistics Which Analyse Clinical
Investigations and Screening
Sensitivity Specificity
Sensitivity:
If a person has a disease, how often will the test be positive (true
positive rate)?
Put another way, if the test is highly sensitive and the test result is
negative you can be nearly certain that they don’t have disease.
Specificity:
If a person does not have the disease how often will the test be negative (true
negative rate)?
In other terms, if the test result for a highly specific test is positive you can be
nearly certain that they actually have the disease.
Sensitivity Specificity
A Sensitive test helps rule out disease (when the result is negative).
Sensitivity rule out or "Snout"
Sensitivity= true positives/(true positive + false negative)
A very specific test rules in disease with a high degree of confidence
Specificity rule in or "Spin".
Specificity=true negatives/(true negative + false positives)
SnNOut & SpPIN!!!!!
A very specific test, when positive, helps rule-in disease
(SpPIn). For example, if a test was 95% specific but only 70%
sensitive, and 10% of patients had the disease, you get the
Disease
No Disease
following 2 x 2 table:
Positive test
14
9
Negative test
6
171
14 out of 25 patients with a positive test have the disease
SnNOut & SpPIN!!!!!
A test that is very sensitive is generally very good at ruling out
disease when negative. The acronym is "SnNOut". For
example, consider a test which is 95% sensitive, 60% specific,
with a pre-test probability of disease of 10%:
Disease
No Disease
Positive test
19
72
Negative test
1
108
Only 1 of 109 patients with a negative test has the disease in
question.
Quick Quiz
A very sensitive test, when negative, helps you:
a: Rule-in disease
b: Rule-out disease
c: Confuse medical students
d: Save money
A test which is highly specific, when positive, helps you:
a: Rule-in disease
b: Rule-out disease
c: Confuse medical students
d: Save money
Two-way table & Calculations
Disease
No Disease
Positive
A
B (false positive)
Negative
C (false negative)
D
Sensitivity: If the patient has the disease, we need to know how often the test will be
positive: This is calculated from
A
A+C
Specificity: If the patient is in fact healthy, we want to know how often the test will
be negative: This is given by:
D
D+B
Two-way table & Calculations
Disease
No Disease
Positive
A
B (false positive)
Negative
C (false negative)
D
Positive Predictive Value: If the test result is positive, what is the likelihood that the
patient will have the condition: A
A+B
Negative Predictive Value: If the test result is negative, what is the likelihood that
the patient will be healthy: This is given by:
D
D+C
Exercise
100 patients were tested for haematemesis. The presence or absence of
gastric cancers was diagnosed from endoscopic findings and biopsy:
Present
Absent
Positive
20
30
Negative
5
45
Calculate the Sensitivity = If gastric cancer is present, there is ? chance of the test
picking it up
Calculate the Specificity = If there is no gastric cancer there is ? chance of the test
being negative – but ? will have a false positive result.
Calculate the PPV = There is a ? chance, if the test is positive, that the patient
actually has gastric cancer.
Calculate the NPV = There is a ? chance, if the test is negative, that the patient does
not have gastric cancer. However, there is still a ? chance of a false negative, i.e. that the
patient does have gastric cancer.
Statistics Which Test Differences
Much more difficult statistics!
Parametric Tests
Analysis of Variance (ANOVA)
Compares the means of two or more samples to see if whether they
come from the same population. A table is created and then used to
calculate f values and P-Values.
t test
Testing the probability that samples come from a population with the
same value. Proves the study has had an effect. It's pretty much
impossible to interpret the t-value without knowing the sample sizes
in the study. For the overwhelming vast majority of situations, a tvalue of 6.67 will be "statistically significant.” The further away from
0 the better. Use P-Values.
Parametric tests are only used when data follow a ‘normal’ distribution.
Mann-Whitney U test
 A non-parametric statistic used when data are not normally




distributed (and thus unsuitable for parametric tests).
Doesn’t state the size of a difference, only the likeliness of
difference. For example a study looking at the ages of two
groups of triaged patients might use a Mann-Whitney U test
to test the hypothesis that there’s no difference in the ages
between the two groups.
Very difficult to understand
Statisticians ‘rank’ data and compare the ranks
Go straight to the P-Value for results
Chi-Squared
 Usually written as X
2
 A measure of the difference between actual and expected
frequencies. Difficult to interpret by itself, dependent on a
number of other factors studied. Gives approximate P-Value and is
inappropriate for small samples.
 Use the P-Value to see likelihood there is no difference between
the groups.
Some papers will give the “Fisher’s exact test” results instead.This is usually
stronger as it gives an exact P-Value. Other non-parametric tests include: the
Wilcoxon Signed-Rank Test, the Kruskal-Wallis Test, and the Friedman Test
Just use the P- Value
And breathe…
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